Healthcare Provider Details

I. General information

NPI: 1811413529
Provider Name (Legal Business Name): BESTCARE PHARMACY JAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2017
Last Update Date: 08/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 MAIN STREET
JAL NM
88252
US

IV. Provider business mailing address

PO BOX 8156
ALBUQUERQUE NM
87198-8156
US

V. Phone/Fax

Practice location:
  • Phone: 575-395-2103
  • Fax: 505-212-0888
Mailing address:
  • Phone: 505-268-2030
  • Fax: 505-212-0888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH00004472
License Number StateNM

VIII. Authorized Official

Name: MRS. RANJITHA PALLAPOTHU
Title or Position: MEMBER
Credential: BE
Phone: 575-395-2103